2/21/12. Outline. Multimodality Imaging In cardiovascular disease. Which imaging modality for which patient?

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1 Outline Cardiovascular disease is the leading cause of death in the United States Multimodality Imaging In cardiovascular disease Explosion of new technology in the last decade to evaluate heart disease Each modality has its advantages and disadvantages Familiarity with techniques is important to order the right test for the right patient Ron Jacob MD, FACC, FASE, FSCCT Medical Director Noninvasive Imaging What does cardiac imaging do for the patient? Which imaging modality for which patient? Cardiac CT Diagnostic Assess Valves Pericardium Masses LV/RV function Assess coronary arteries Guide to therapy Pericadiocentesis Cardioversion Revascularization Prognosis Nuclear Cardiology CMR Appropriate Use Criteria Cardiac Imaging Echocardiography Cardiac CT Cardiac MRI Nuclear Imaging 1

2 How does echocardiography work? Echocardiography Works on the principle of the reflection of energy from the tissues (ultrasound) Ultrasonic frequencies are between 2 10 million cycles /sec Piezoelectric crystals generate ultrasonic waves when stimulated by electricity A digital image is created from the received signal amplitude Echocardiography Workhorse in imaging of patients with heart disease 3D echo, TDI, strain rate imaging Flow/hemodynamic information TEE for high resolution images Portable Fast Urgent / emergent indications Relatively inexpensive Safe Who is a candidate for Echocardiography? Patient Preparation Indications General evaluation of cardiac structure and function Evaluation in the acute setting Evaluation of valvular disease Evaluation of Aortic disease Evaluation of Heart failure Evaluation of Congenital heart disease Stress testing Contraindications Morbid obesity? TEE NPO for 4 6 hours IV access Remove dentures ICU patients TEE check list TTE No preparation necessary How does Cardiac CT work? Coronary CTA with 64 Slice MDCT Xray beams pass through the body Beams are collected in a detector array The information is is digitized in to pixel elements Gray scale information is assigned a value Hounsfield Unit Recent advances have allowed CT technology to provide enough spatial and temporal resolution to image small cardiac structures such as the coronary arteries. Coronary CTA is not a substitute for invasive coronary angiography Non-invasive diagnostic modality with high negative predictive value (98-99%). 2

3 2/21/12 Patient Selection Ideal candidates for coronary CTA: Low-Intermediate risk patients 30-70% pre-test probability for coronary disease Useful after equivocal or non-diagnostic stress test Age < 75 years Normal sinus rhythm Poor candidates for coronary CTA: Likely to have heavy calcification of coronary arteries Coronary stents Frequent arrhythmia (especially atrial fibrillation) Uncontrolled tachycardia Creatinine 1.8 mg/dl Morbidly obese ( radiation dose, SNR) Patient preparation CMP renal insufficiency IV access for contrast dye Prep for contrast dye if allergic Weight limits for scanner ICU patients may be difficult to transport What about the risk of radiation? Consider Risks and benefits of any testing Hypothesis that radiation from medical testing causes cancer controversial Protocols via cardiac CT can be optimized to reduce radiation Newer scanners can perform scans with less radiation Non Coronary Application of Cardiac CT Evaluate ventricular function (limited echo/mri) Evaluation of cardiac mass /thrombus (limited echo/mri) Evaluation of pericardium (limited echo/mri) Electrophysiology applications (ARVD/C, pulmonary veins pre/post- A-fib ablation, coronary veins pre-crt) Assessment of complex congenital heart disease, including coronary artery anomalies, great vessels, cardiac chambers and valves Evaluate for aortic dissection /dilatation 3

4 2/21/12 How does MRI work? Hydrogen is the most prevalent element in the body as it is present in water and fat Hydrogen has a spin A moving charge generates a magnetic field A radiofrequency pulse changes the spin of the Hydrogen atoms and the retransmitted energy is recorded A digital image is constructed from the retransmitted energy Cardiovascular MRI Quantify ventricular volumes/mass /function, blood flow, and stress perfusion High spatial resolution of cardiac anatomy (0.8-2 mm) Evaluate extra-cardiac anatomy Tissue characterization No iodinated contrast No ionizing radiation One Stop shopping MRI Limitations Device contraindications Pacemakers ICD s Cerebral aneurysm clips Metallic foreign bodies Cochlear implants and hearing aids Claustrophobia Arrhythmias problematic Breath hold requirements Not portable Expense Limited availability MDCT Limitations Ionizing radiation Calcium Iodinated contrast use Not portable Arrhythmias problematic Limited availability Don t use if: Atrial fibrillation Likely to have calcium (very elderly, ESRD) Renal insufficiency (Cr > mg/dl) 4

5 Nephrogenic Systemic Fibrosis Patient Preparation BMP make sure the GFR> 30 Occurs in patients with renal insufficiency who get gadollinium Scleroderma like illness Approximately 215 cases reported since May 2008 No cases reported when GFR > 30ml/min/m 2 Associated with significant mortality and morbidity CMR can be performed without gadollinium for some indications Pacers/ ICD relative contraindiation IV access if gadolinium to be administered Severe Claustrophobia Morbid obesity How does nuclear imaging work? Nuclear Imaging Radioactive tracer administered during rest and stress Tracer accumulates in the heart Transmitted photons are captured by the Anger camera Signal converted into a digital image SPECT / PET / MUGA Mostly used for stress testing Can be used to evaluate LV Function Widely available Easy to perform Limitations Morbid obesity Ionizing radiation Artefacts from diaphragm/breast Patient Preparation IV site required No V/Q scan in the prior 24 hours Patient must be able to lift their hands above their head Morbid obestiy an issue Indication Evaluate ejection fraction When to use each modality Chest pain / acute coronary syndrome Preferred Test TTE; ± MRI, CT, nuclear (MUGA) High clinical risk (EKG changes, MI) Cardiac catheterization CAD with prior stents CAD with prior CABG Low to intermediate clinical risk Pre-operative evaluation Valvular heart disease, murmur Aortic disease (dissection, aneurysm) Pericardial disease Congenital heart disease Cardiac masses Obese patients Cardiac catheterization, stress nuclear, stress echo Cardiac catheterization, stress nuclear, stress echo, coronary CTA Stress echo, stress nuclear, coronary CTA, stress MRI Cardiac catheterization, coronary CTA, stress nuclear, stress echo, stress MRI TTE, ± TEE MRI or CT, ± TEE (acute dissection) TTE, ± TEE, MRI, CT Echocardiography and MRI or CT MRI, CT, TEE, ± PET-FDG How obese? 5

6 What does the future hold? Thank you Echocardiography strain imaging, myocardial mechanics, 3 D, flow vortex imaging CT CT perfusion, faster scanners, lower radiation, quantitative blood flow MRI T1 Mapping, Newer agentss (Manganese) Excellence is an art won by training and habituation. We do not act rightly because we have virtue or excellence, but we rather have those because we have acted rightly. We are what we repeatedly do. Excellence, then, is not an act but a habit. Aristotle Nuclear Ultrafast systems, hybrid systems PET/CT, newer isotopes 6

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